The nation's aging population experiences high rates of chronic disease that are associated with excess morbidity and mortality, and concomitant high medical costs. Care for older adults with chronic disease is typically fragmented, and lacking continuity over time and across settings. Neither older adults with chronic disease, nor their informal family caregivers, typically have the knowledge or self-management skills necessary to manage these conditions. The mismanagement of chronic disease has important implications for both the individual and society, resulting in poor health outcomes, as well as avoidable health care costs. This Phase I application will establish the feasibility, acceptability, and short-term effectiveness of a unique Coordinated Telehealth Care Program that integrates strategies for home telehealth/remote patient monitoring and care coordination for rural, older patients with a diagnosis of congestive heart failure (CHF). The focus on CHF is because it is one of the most prevalent and costly chronic diseases in the Medicare population. Specific study aims are to: 1) develop a low cost, effective remote patient monitoring system that uses low cost PCs and web 2.0 technology to monitor symptoms and enhance self-management skills of the older adult and his/her caregiver;2) develop and implement the Coordinated Telehealth Care Program that incorporates this low cost remote patient monitoring system for older, rural Arkansans with a diagnosis of CHF;3) evaluate the program in a randomized controlled pilot study using the RE-AIM conceptual model;and, 4) develop and submit a Phase II application, based on Phase I evaluation results. The results from the Phase I study, specifically, the differences in outcomes between treatment and usual care groups in the endpoints (e.g., number of re- hospitalizations) will be used to predict sample size needed for the Phase II application. Environment and Health Group is collaborating with the Reynolds Institute Center on Aging (RICOA) and the Reynolds Department of Geriatrics at the University of Arkansas Medical School, one the largest academic geriatric medicine programs in the country, and with Medullan Inc., a Cambridge, MA-based health software development company. Geriatric clinical investigators from the RICOA have collaborated on this proposal, ensuring that the home telehealth/remote patient monitoring and care coordination program addresses issues unique to the geriatric patient with CHF. RICOA investigators will implement the program among rural, older Arkansans, while Medullan will develop the needed software. The goal of the Phase II SBIR will be to develop, implement, and evaluate, in a robust randomized trial, a home telehealth/remote patient monitoring care coordination program for older persons with a diagnosis of CHF in rural areas. The subsequent Phase II application, will lead to an innovative service delivery model not only for older patients with CHF, but for older adults with multiple co-morbidities and geriatric syndromes, with the potential to be replicated and marketed in rural areas across the country. PUBLIC HEALTH RELEVANCE: The management of chronic disease is an enormous public health challenge with the rapid aging of the United States population. The management of chronic diseases such as heart disease and diabetes presents special problems in rural areas because of the shortage of health care providers, their lack of training in geriatrics, and the long distances patients have to travel to access care. The proposed project will develop and evaluate an innovative approach to care coordination and telehealth in rural patients with congestive heart failure. The proposed project is designed to improve patient health and reduce costs by using innovative low cost technology to promote better care coordination.